West Coast Centre for Learning - Foundations in Social Skills _ Initial Questionnaire - Youth Ages 14-21 WINTER (In-person) Jan 13

Foundations in Social Skills

Cost: $1395

No upcoming class

Tuesday 4:00 PM - 5:00 PM

January 13, 2026, January 20, 2026, January 27, 2026, February 3, 2026, February 10, 2026, February 17, 2026, February 24, 2026, March 3, 2026, March 10, 2026

The Professional Centre, Building C, 4/F, Suite 402

3211 152nd Street, Surrey, BC, V3Z 1H8

The Professional Centre, Building C, 4/F, Suite 402

3211 152nd Street, Surrey, BC, V3Z 1H8

Parent/Guardian

You will receive a confirmation by email.

Relationship

First name *

Last name *

Email *

Mobile *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Does your child live with you full time or part time?

Other parent (Optional)

Relationship

First name *

Last name *

Email *

Mobile *

Address

City

Country

State/Province

Zip/Postal code

Does your child live with you full time or part time? *

What is your preferred method of communication? *

Phone Text Email Zoom

Is your teen or young adult attending school *

Yes No

If yes, what is the name of the school they attend?

Background Questions

The following questions will help us to understand how your teen or young adult is coping socially. *

Difficulty conversing with peers No friends Teased or bullied Never receives invitations for outside social gatherings i.e birthday parties/events Inappropriate friendships (younger/older) Self Isolating Aggression toward peers No social gatherings outside school Other

If other, please specify.

Does your teen or young adult want to have friends and will they be motivated to make new friends and learn new strategies? *

Yes No Somewhat

If somewhat, please elaborate.

What special interests or activities does your teen or young adult engage in?

School Information (for teens):

The following questions refer to your teen's performance at school.

Is your teen on a modified or adapted program? *

Yes, adapted Yes, modified No N/A

What type of classroom setting is your teen currently placed in? *

All day mainstreamed classroom Majority mainstream with some Special Education or therapeutic classes All day self contained Special Education classroom Majority Special Education with some general education classes Homeschool/Online School Situation Other N/A

If other, please specify.

Questions About Behaviour:

Does your teen or young adult have any behaviour concerns that may limit/interfere with their participation in the program. *

Yes No

If yes, please explain.

Questions About Participation:

The following questions refer to your family's ability to attend and participate.

Will your teen or young adult be motivated to attend sessions on a regular basis? *

Yes No Somewhat

If somewhat, could you please elaborate?

It's important not to institute change during the program period (i.e. changes to medication, residence, school, etc.). *

Will there be any big changes for your teen or young adult during the program period?

Yes No

How did you hear about us? *

Service provider (Pediatrician, General Practitioner, Psychologist, Counsellor) BC Psychological Association Internet Search Family / Friend Other

If other, please specify. If by service provider/family/friend, please list their name below.

Would you like to receive our newsletter with helpful parenting tips, program information, and special offers. (You can unsubscribe at any time) *

Yes please! No thanks.

I consent to having photographs and work samples of my teen or young adult to be used by West Coast Centre for Learning in promotional material. * *

Yes No

Will you be accessing funding to pay for the program? *

Yes, Autism Funding Yes, School Funding No, bill me privately

If school funding, please list school below.

Please list any questions, comments or concerns that you may have, if any:

Electronic signature

Please sign your name inside the box

Draw Type

×

Thank-you for completing the Foundations in Social Skills pre-interview questions.

Upon submitting this form, you will receive a copy of your responses, and a confirmation email containing with a link to schedule your intake interview. During the interview, which will take approximately 30 minutes, you will have the opportunity to discuss your responses, ask questions, and clarify any details.

Thank you for choosing West Coast Centre for Learning, we look forward to connecting with you. If you require immediate assistance, please feel free to contact us: info@wccl.ca or (778) 839-5515

By submitting this form, you consent to West Coast Centre for Learning collecting and using your information to respond to your inquiry. For details on how your data is stored and protected, please review our Privacy Policy.